National University Cancer Institute, Singapore A Member of the Cochrane Nursing Care Field
Correspondence: Lang Siew Ping, PhD, RN, BSN, Advanced Diploma in Nursing (Oncology), National University Cancer Institute, 5 Lower Kent Ridge Road, Singapore 119074 ( firstname.lastname@example.org).
This is a summary of a Cochrane Review. The full citation and the names of the researchers who conducted the review are listed in the Reference section below.The author has no funding or conflicts of interest to disclose.
There is extensive evidence showing that most patients with an advanced illness and their caregivers choose their home as the designated place to die. Home palliative care services provide expert management of the symptoms and problems experienced toward the end of life. Therefore, understanding the clinical effectiveness of these services will assist nurses to aid patients with advanced illness in their decision making for accessing home palliative care services.
The objectives of the review1 were to quantify the effect of home palliative care services for adults with advanced illness and their family member caregivers on patients’ odds of dying at home, to examine the clinical effectiveness on outcomes other than death at home associated with these services, and to synthesize the current evidence on cost-effectiveness.
The review included 23 studies containing 37 561 participants and 4042 family members. Sixteen studies were randomized controlled trials (RCTs), 4 were cluster controlled trials (CCTs), and 3 were controlled before and after studies (CBAs), 1 of which was an interrupted time series analysis with a nested CBA. The intervention of interest was home palliative care services consisting of a team delivering either specialist or intermediate palliative care either for patients or their family caregivers or for both. The team aimed to support both patients and family caregivers physically and psychosocially at the home setting. The intervention was compared with usual care, which could include community care, hospital care, and palliative or hospice care. Patients had to have a severe or advanced disease (malignant or non-malignant), no longer responding to curative/maintenance treatment or symptomatic, or both to be included in the study. Patients and family caregivers had to be 18 years or older. The primary outcome measure was death at home and secondary outcomes included time the patient spent at home, satisfaction with care, pain, other symptoms, physical function, quality of life, and caregiver prebereavement and postbereavement outcome. Economic data included costs for hospital, institutional care, community care, informal care, equipment, and medication.
Six of the 16 RCTs were considered of high methodological quality, whereas none of the 4 CCTs reached high quality. Random allocation was described explicitly in 9 trials. Only 4 trials explicitly mentioned lack of participants’ blinding and 2 trials were able to follow up 80% or more on all outcomes analyzed. Nine studies (8 RCTs and 1 CCT) measured participant characteristics and outcomes at baseline. Of the 3 CBAs, 2 were considered high quality, whereas the interrupted time series analysis was not. Six studies, generally with small sample sizes, examined cost-effectiveness and were considered high-quality economic evaluations. However, the differences in methods and resources used have limited the application of meta-analysis.
Meta-analysis (7 trials, 1222 patients) showed statistically significantly higher odds of dying at home for patients with illnesses such as cancer, co ngestive heart failure, and chronic obstructive pulmonary disease when compared with patients receiving usual care (odds ratio, 2.21; 95% confidence interval, 1.31–3.71; P = .003).
Narrative synthesis showed evidence of small but statistically significant positive effects of home palliative care services on reducing symptom burden for patients (3 trials, 2107 patients) and of no effect on caregiver grief (3 trials, 2113 caregivers) when compared with usual care.
There were conflicting results for pain control (9 trials), satisfaction with care (6 trials), and cost-effectiveness (6 trials).
Home palliative care services increase the odds of dying at home and reduced symptom burden for patients with malignant and nonmalignant conditions without affecting caregiver grief. More high-quality research is needed to determine cost-effectiveness.
Implications for Practice
Results from a systematic review demonstrate that patients with advanced illness benefited from home palliative care services.
1. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost- effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013; 6: CD007760. doi:10.1002/14651858.CD007760.pub2.